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Understanding adult acquired megacolon
UNDERSTANDING ADULT ACQUIRED MEGACOLON When treated separately, the combination of factors creating this condition can be dealt with successfully. JUDITH PEREIRA FRANCIS D. HORRIGAN Megacolon, or "large bowel," is an abnormal dilatation of the colon. Adult acquired megacolon is a chronic disorder that may be present in the elderly person who has a long history of problems with elimination. Moreover, by virtue of increasing longevity, older adults are at risk to develop many of the physical conditions that may contribute to this problem(l). Thus, it is important to consider the possibility of acquired megacolon, especially ifa history of constipation or laxative use has been identified. Understanding normal large bowel function and knowing the etiology, symptoms, and mechanisms of this condition will enable the nurse to devise an appropriate care plan for patients with this condition in the acute, long-term, or homecare setting.
Normal Bowel Functions Important functions of the normal colon are reabsorption of significant quantities of water and electrolytes, elimination ofundigestable material, and regulation of the bacterial ecosystem. Colonic motility is of prime concern in these functions. This movement is a muscular function depending on the nature of the colon's smooth muscle, which has intdnsic "pacemaker" and coordinating acJudith Pereira, RN, MS, is a clinical nurse specialist in gerontological nursing at Noble Hospital in Westfield, MA. Francis D. Horrigan, MD, is president of the medical staffat Noble Hospital.
16 Geriatric Nursing January/February 1987
tivity. Colonic muscle also responds to hormonal, autonomic and somatic neural activity(2). Entry of foodstuff into the small bowel produces three colonic activities: retrograde peristalsis that delays movement in the right colon aiding absorption of water and electrolytes; segmental contraction to aid mixing; and mass movement that moves stool from the transverse colon, sigmoid, and rectum and produces an urge to defecate(3). The urge to defecate may be modified by physical activity, neurological status, chemicals (including drugs), and the condition of the bowel itself. This activity is characterized by a controlled reflex arc. The distended rectum serves as a stimulus to the afferent limb of the reflex arc. This produces a relaxation of the smooth muscle of the internal anal sphincter and thus allows entry of the stool into the anal canal. Actual defecation usually involves abdominal muscle contraction to increase downward pressure and relaxation of the external anal sphincter(3). Alteration of this normal sequence may result in megacolon. The diameter of the colon is usually measured on a plain film of the abdomen (see photo showing dilation of colon). A diameter of eight to ten centimeters of transverse colon is usually accepted as significantly dilated(4).
Symptoms and Diagnosis Acquired megacolons in the elderly have diverse etiologies and present a constellation of signs, symptoms, and complications. Most of these conditions have several features in common, which together produce the patient's difficulty but which, when considered separately, can suggest effective remedies. The common features usually include colonic hypomotility, functional or structural
obstruction, and altered patient responsiveness. Evaluation of the contributors to this state may produce a specific diagnosis and treatment, or may result in no specific diagnosis and may be followed with supportive treatment. The patient presents with abdominal distention, due to the increased abdominal contents and presence of large amounts of flatus. Lack of effective elimination is evident in absence of stool, smearing, or diarrheal incontinence. The patient may complain of anorexia, nausea, fatigue, and headache. Symptoms of acute intestinal obstruction are usually absent unless distention acutely compresses and obstructs portions of the small bowel(4). Special attention must be paid to conditions that change the patient's ability to perceive the urge to defecate. For example, neuropathies, medications, central nervous system disease, or psychiatric conditions may have altered the patient's ability to recognize this need. Patients may also be unable to respond to or act on the urge to move their bowels b e cause of neurological conditions or enforced immobility. Additionally, such metabolic, vascular, or systemic diseases as diabetes, hypothyroidism, scleroderma, amyloidosis, or electrolyte imbalances may have rendered the colon incapable of creating a proper reflex arc(4). Structural abnormalities such as adhesions, radiation damage, or ischemic or post-infection strictures must be identified and corrected. Complications of acquired megacoIon may include sigmoid volvulus, stercoral ulcer with bleeding or perforation, or sepsis(5). Diagnosis of megacolon is based on an analysis of a carefully taken history and a physical examination that pays attention to bowel pattern,
some neuropsychiatric conditions may have to be modified. For example, selection of medication for the patient with Parkinson's disease or psychosis should take into account current bowel status(8). To provide a care plan that meets the individual needs of the patient, a nursing assessment must cover several areas, including: history of elimination pattern, medication regimen, nutritional assessment, psychosocial status, and measurement of comfort Upright film of abdomen showing marked dilation of colon. and activity levels. Assessment of bowel elimination must include a history of the bowel pattern, use of elimination aids, frequency and consistency of stool, and presence of flatus. This information will vary greatly from one patient to another. For example, patients may recount bowel movement that occurs less than once per week to less than once per month. The stool consistency is usually described as hard. Most patients will report difficulty passing flatus, which may be verified by the patients' distended appearance. (See Barium enema X ray showing Photograph of the abdomen demonstrates photograph demonstrating marked dilated sigmoid colon and rectum, marked abdominal distention. abdominal distention.) In addition to assessing the elimination pattern, a nutritional history is essential. A diet that is low in roughage coupled with poor fluid intake would certainly contribute to the risk ofconstipation. Another important factor to consider is activity level. Adequate exercise is known to aid the process of bowel elimination(9). Many patients will report a gradual decrease in mobility or decreased activity tolerance, occurring with increased constipation. Colonic distention has produced atelectasis of the left lower lobe. Medications can, of course, be a factor in constipation. The nurse must determine if the patient is takuse of constipating medications, his- ation of electrolytes and renal and ing anything that decreases intestinal motility. Many drugs commonly tory of metabolic, psychiatric, and thyroid function tests. used by the elderly will affect transit neurological conditions, and history Care and Treatment time of fecal contents. For example, of injury. Radiological evaluation The medical treatment ofmegaco- anticholinergics, opiate preparamay include plain films of the abdomen, and barium studies (see barium Ion includes identifying and correct- tions, and many antidepressants inenema x-ray). Endoscopy may reveal ing deficiencies. For example, con- crease the risk of constipation(10). Admission data also include the several conditions such as melanosis trol of diabetes, correction of electro(indicative oflaxative abuse) or stric- lyre imbalances, and review of the measurement of abdominal girth. tures from radiation, tumor, or infec- patient's medication regimen are all This measurement may then be used tion. Anorectal manometry may be easily done. Surgical treatment may as a reference point, since the patient performed for the purpose of assess- include removal of strictures, colon may deny discomfort or be unable to ing neurological status(6). Blood resection for volvulus, or anal cor- describe comfort level. The abdomichemistry profile may include evalu- rective surgery(7). Treatment of nal girth is always taken in the same
Geriatric Nursing January/February 1987 17
SAMPLE
NURSING
CARE PLAN
Nursing Diagnosis: Alteration in bowel elimination-constipation related to inability to initiate defecation. Goal: To prevent impaction/obstruction by assisting the patient to move bowels regularly (2-3 BMs per week).
Interventions: 1. Assess bowel sounds daily and record. 2. Measure and record abdominal girth daily (measure in same place, at same time, and position the patient the same way). 3. Assess and document the patient's subjective description of discomfort. . Administer Harris Flush: Slowly instill 800-1000 cc of warm tap water. (Hold enema bag at level of bed, gradually raising bag to 18-24" above level of bed. Lower bag immediately upon completion of procedure.) Observe patient throughout procedure.* 5. Provide optimum positioning for further evacuation; patient should be sitting on commode or toilet. 6. Encourage patient to massage abdomen, robbing from right to left to enhance movement of feces. 7. Provide digital stimulation of the extemal sphincter if appropriate. 8. Ensure privacy and promote relaxation through a supportive attitude. . Consult with physician regarding appropriate fiber and fluid intake if the patient's diet is restricted or in the presence of disease (for example, congestive heart failure). 10. Together with the patient, arrange a dietary consultation with the patient to plan meals and supplements that will provide an adequate amount of fiber. 11. Teach the patient about fiber and its role in maintaining regularity. 12. Allow two weeks to evaluate care plan: record all BMs-amount, color, consistency, and time of BM.** *Discontinue immediately if the patient complains of severe discomfort,weakness, or anxiety,or if the nurse observes signs of syncope, that is, weakness, lightheadedness,or change in pulse, skin temperature, or color. **A mild laxativemay be needed until the program is established.Consultwith physician regarding appropriatedrug.
place, and the patient's position remains constant for each measurement. The patient is measured daily and always at the same time. Presence of bowel sounds are determined, and the patient's subjective description of comfort or discomfort is elicited, if possible. This information provides guidelines for establishing a bowel program aimed at preventing complica-
18 Geriatric Nursing January/February1987
tions of acquired megacolon while enhancing patient comfort. Specific nursing interventions will be determined according to the individual needs of the patient (see Sample Care Plan above). A successful method for assisting in maintaining motility and in expelling flatus is the Harris Flush(l 1). This procedtire is a form of colonic irrigation in which a moderate
amount (800ce) of warm tap water is slowly introduced into the rectum. The enema bag is initially held at the level of the bed at the start of the procedure and is gradually raised to 1824 inches above the level of the bed to ensure continuous flow into the rectum. As soon as the fluid is completely emptied, the bag is lowered below the level of the bed. This procedure has a siphoning effect: It not only withdraws flatus, but also ensures an immediate return of fluid. It is very safe, because it eliminates the possibility of too much water being absorbed by the colon and so reduces the risk of fluid overload to the cardiovascular system. (Since many elderly suffer from compromised cardiac output, absorption of additional water could precipitate an episode of congestive heart failure.) After completion of the Harris Flush, most patients will experience relief from flatus and may show a measurable decrease in abdominal girth. But the flush does not guarantee an immediate return of feces. The colon is grossly distended, and the fluid used in the irrigation may remain in the very lowest portions of the sigmoid, colon, and rectum, while the feces may be above this level. Therefore, bowel movement may be delayed for up to 24 hours. The patient may then expel a large amount of liquid stool (over 1,000cc), and with great force. Such fluid is considered "third space" content, and loss of it does not significantly change hemodynamic status(3). However, sudden evacuation could precipitate defecation syncope, thought to be associated with sudden decompression of the rectum(12). Therefore, close observation of the patient is essential during and after this procedure. In addition to the Harris Flush, other methods to help establish a bowel program may be used. Bulk formers may soften stools, laxatives can move intestinal contents, and suppositories can stimulate evacuation. Providing the patient with a regular elimination time in addition to allowing for privacy are important considerations when planning care. Besides the establishment of a bowel program, several other factors
are important to consider in planning nursing interventions. Measures to provide comfort and promote activity tolerance, maintenance of pulmonary hygiene, nutritional counseling, and emotional support should be included in the care plan(l 3). A diet ensuring that the patient is receiving and tolerating appropriate amounts of roughage and fluids must be planned. For example, if the patient has trouble chewing, prune juice or bran added to warm cereal may be substituted for fresh fruits and vegetables. The patient's progress may be evaluated during hospitalization in order to make necessary adjustments before discharge. The patient with acquired megacoIon may be experiencing considerable abdominal distention which may place pressure on the diaphragm, thus compromising the ability to ful-
ly expand the lungs. The patient is at risk to develop complications such as atelectasis or pneumonia (see x ray of lung showing atelectasis). Thus it is essential to encourage coughing and deep breathing and to frequently change the patient's position. Comfort measures include positioning the patient according to his or her own preference. (Positioning the patient at a 45-degree angle while in bed will not serve to alleviate pressure on the diaphragm.) Most patients will want to sit upright and use a footstool, which will help prevent dependent edema. Activities such as bathing and ambulation should be planned with frequent rest periods. However, as the patient's physical status improves, the nurse and patient may plan activities aimed at increasing tolerance to physical activity in preparation for discharge. Many elderly patients are quite
ETIOLOGIES OF ADULT ACQUIRED MEGACOLON CATEGORY
EXAMPLE
OBSTRUCTION Intrinsic
Tumor Stricture
Radiation Extrinsic
Tumor Adhesion Endometriosis Radiation
PSYCHIATRIC
Psychosis Neurosis Dementia
NEUROLOGICAL
Parkinson's disease Multiple sclerosis Cord lesions Drugs Dystrophies
CONNECTIVE TISSUE DISEASE
Progressive systemic sclerosis Lupus Amyloidosis
METABOLIC
Hypokalemia Hypocalcemia Hypothyroidism Diabetes Lead poisoning
MISCELLANEOUS
Idiopathic Pseudo obstruction Laxative abuse Painful back Pelvic conditions Irritable bowel syndrome
preoccupied with bowel functioning. It is important to recognize that this concern may become magnified during hospitalization for acquired megacolon. As a result, suggestions for appreciable changes in everyday routines may be met with considerable resistance, and attempts to change habits of a lifetime are probably fruitless. Nursing efforts are perhaps best directed toward preventing complications. The nurse can establish a relationship with the patient based on trust only in a nonjudgmental and supportive environment; in this way, he or she can work to alleviate the patient's concerns. Acquired megacolon is a condition that can be treated successfully in the elderly population through a collaborative effort on the part of physician, nurse, and patient. Promotion of a bowel maintenance program and a care plan designed to increase activity levels and enhance comfort may be successfully applied in any care setting. References I. Stefll, B. M., ed. lIandbook of Gerontological Nursing. New York, Van Nostrand Reinhold Co., 1984. 2. Spiro, H. M. Clinical Gastroenterology 3rd ed. New York, Maemillian Publishing Co., 1983. 3. Guyton, A. C. Textbook of Medicol Physiology 7th ed. Philadelphia, W.B. Saunders Co., 1986. 4. Sleisenger,M. H., and Fordtran, J. S. Gastrointes-
tinal Disease: Pathophysiology Diagnosis Management. Philadelphia, W.B. Saunders Co. (To be published) 5. Andres, R., and Hazzard, W. R. Principles of Geriatric Medicine. New York, McGraw-Hill Book Co., 1984. 6. Taylor, I., and others. An assessment ofanorectal motility in the management of adult megacolon. Br.J.Surg. 67:754-756, Oct. 1980. 7. Ryan, P. Sigmoid volvulus with and without magacolon. Dis.Colon Rectunt 25:673-679, Oct. 1982. 8. Brocklehurst, J. C. Disorders of the Lower bowel in old age. Geriatrics 35:47-54, May 1980. 9. Gioiella, E., and Bevil, C. Nursing CareoftheAging Client. East Norwalk, CT, Appleton-CenturyCrofts, 1984. 10. Bruuner, Lilian, and Suddarth, Doris. Textbook of Medical-Surgical Nursing. 5th Ed. Philadelphia, J.B. Lippincolt Co., 1984. I I. King. E. M., and others. Illustrated Manual of Nursing Techniques. Philadelphia, J.B." Lippincott Co., 1977. (2nd ed. 1981) 12. Hurst. J. W. The tteart. 6th ed. New York, McGraw-Hill Book Co., 1986. 13. Carpenito, L. J. Nursing Diagnosis: Application to ClinicalPractice. Philadelphia, J.B. Lippincott Co., 1983.
Acknowledgment We would like to thank Lincoln Russin, MD, and Bridget Bedard, BA, for their help with taking the photographs that appear in this article.
Geriatric Nursing January/February 1987 19
Normal Bowel Functions Important functions of the normal colon are reabsorption of significant quantities of water and electrolytes, elimination ofundigestable material, and regulation of the bacterial ecosystem. Colonic motility is of prime concern in these functions. This movement is a muscular function depending on the nature of the colon's smooth muscle, which has intdnsic "pacemaker" and coordinating acJudith Pereira, RN, MS, is a clinical nurse specialist in gerontological nursing at Noble Hospital in Westfield, MA. Francis D. Horrigan, MD, is president of the medical staffat Noble Hospital.
16 Geriatric Nursing January/February 1987
tivity. Colonic muscle also responds to hormonal, autonomic and somatic neural activity(2). Entry of foodstuff into the small bowel produces three colonic activities: retrograde peristalsis that delays movement in the right colon aiding absorption of water and electrolytes; segmental contraction to aid mixing; and mass movement that moves stool from the transverse colon, sigmoid, and rectum and produces an urge to defecate(3). The urge to defecate may be modified by physical activity, neurological status, chemicals (including drugs), and the condition of the bowel itself. This activity is characterized by a controlled reflex arc. The distended rectum serves as a stimulus to the afferent limb of the reflex arc. This produces a relaxation of the smooth muscle of the internal anal sphincter and thus allows entry of the stool into the anal canal. Actual defecation usually involves abdominal muscle contraction to increase downward pressure and relaxation of the external anal sphincter(3). Alteration of this normal sequence may result in megacolon. The diameter of the colon is usually measured on a plain film of the abdomen (see photo showing dilation of colon). A diameter of eight to ten centimeters of transverse colon is usually accepted as significantly dilated(4).
Symptoms and Diagnosis Acquired megacolons in the elderly have diverse etiologies and present a constellation of signs, symptoms, and complications. Most of these conditions have several features in common, which together produce the patient's difficulty but which, when considered separately, can suggest effective remedies. The common features usually include colonic hypomotility, functional or structural
obstruction, and altered patient responsiveness. Evaluation of the contributors to this state may produce a specific diagnosis and treatment, or may result in no specific diagnosis and may be followed with supportive treatment. The patient presents with abdominal distention, due to the increased abdominal contents and presence of large amounts of flatus. Lack of effective elimination is evident in absence of stool, smearing, or diarrheal incontinence. The patient may complain of anorexia, nausea, fatigue, and headache. Symptoms of acute intestinal obstruction are usually absent unless distention acutely compresses and obstructs portions of the small bowel(4). Special attention must be paid to conditions that change the patient's ability to perceive the urge to defecate. For example, neuropathies, medications, central nervous system disease, or psychiatric conditions may have altered the patient's ability to recognize this need. Patients may also be unable to respond to or act on the urge to move their bowels b e cause of neurological conditions or enforced immobility. Additionally, such metabolic, vascular, or systemic diseases as diabetes, hypothyroidism, scleroderma, amyloidosis, or electrolyte imbalances may have rendered the colon incapable of creating a proper reflex arc(4). Structural abnormalities such as adhesions, radiation damage, or ischemic or post-infection strictures must be identified and corrected. Complications of acquired megacoIon may include sigmoid volvulus, stercoral ulcer with bleeding or perforation, or sepsis(5). Diagnosis of megacolon is based on an analysis of a carefully taken history and a physical examination that pays attention to bowel pattern,
some neuropsychiatric conditions may have to be modified. For example, selection of medication for the patient with Parkinson's disease or psychosis should take into account current bowel status(8). To provide a care plan that meets the individual needs of the patient, a nursing assessment must cover several areas, including: history of elimination pattern, medication regimen, nutritional assessment, psychosocial status, and measurement of comfort Upright film of abdomen showing marked dilation of colon. and activity levels. Assessment of bowel elimination must include a history of the bowel pattern, use of elimination aids, frequency and consistency of stool, and presence of flatus. This information will vary greatly from one patient to another. For example, patients may recount bowel movement that occurs less than once per week to less than once per month. The stool consistency is usually described as hard. Most patients will report difficulty passing flatus, which may be verified by the patients' distended appearance. (See Barium enema X ray showing Photograph of the abdomen demonstrates photograph demonstrating marked dilated sigmoid colon and rectum, marked abdominal distention. abdominal distention.) In addition to assessing the elimination pattern, a nutritional history is essential. A diet that is low in roughage coupled with poor fluid intake would certainly contribute to the risk ofconstipation. Another important factor to consider is activity level. Adequate exercise is known to aid the process of bowel elimination(9). Many patients will report a gradual decrease in mobility or decreased activity tolerance, occurring with increased constipation. Colonic distention has produced atelectasis of the left lower lobe. Medications can, of course, be a factor in constipation. The nurse must determine if the patient is takuse of constipating medications, his- ation of electrolytes and renal and ing anything that decreases intestinal motility. Many drugs commonly tory of metabolic, psychiatric, and thyroid function tests. used by the elderly will affect transit neurological conditions, and history Care and Treatment time of fecal contents. For example, of injury. Radiological evaluation The medical treatment ofmegaco- anticholinergics, opiate preparamay include plain films of the abdomen, and barium studies (see barium Ion includes identifying and correct- tions, and many antidepressants inenema x-ray). Endoscopy may reveal ing deficiencies. For example, con- crease the risk of constipation(10). Admission data also include the several conditions such as melanosis trol of diabetes, correction of electro(indicative oflaxative abuse) or stric- lyre imbalances, and review of the measurement of abdominal girth. tures from radiation, tumor, or infec- patient's medication regimen are all This measurement may then be used tion. Anorectal manometry may be easily done. Surgical treatment may as a reference point, since the patient performed for the purpose of assess- include removal of strictures, colon may deny discomfort or be unable to ing neurological status(6). Blood resection for volvulus, or anal cor- describe comfort level. The abdomichemistry profile may include evalu- rective surgery(7). Treatment of nal girth is always taken in the same
Geriatric Nursing January/February 1987 17
SAMPLE
NURSING
CARE PLAN
Nursing Diagnosis: Alteration in bowel elimination-constipation related to inability to initiate defecation. Goal: To prevent impaction/obstruction by assisting the patient to move bowels regularly (2-3 BMs per week).
Interventions: 1. Assess bowel sounds daily and record. 2. Measure and record abdominal girth daily (measure in same place, at same time, and position the patient the same way). 3. Assess and document the patient's subjective description of discomfort. . Administer Harris Flush: Slowly instill 800-1000 cc of warm tap water. (Hold enema bag at level of bed, gradually raising bag to 18-24" above level of bed. Lower bag immediately upon completion of procedure.) Observe patient throughout procedure.* 5. Provide optimum positioning for further evacuation; patient should be sitting on commode or toilet. 6. Encourage patient to massage abdomen, robbing from right to left to enhance movement of feces. 7. Provide digital stimulation of the extemal sphincter if appropriate. 8. Ensure privacy and promote relaxation through a supportive attitude. . Consult with physician regarding appropriate fiber and fluid intake if the patient's diet is restricted or in the presence of disease (for example, congestive heart failure). 10. Together with the patient, arrange a dietary consultation with the patient to plan meals and supplements that will provide an adequate amount of fiber. 11. Teach the patient about fiber and its role in maintaining regularity. 12. Allow two weeks to evaluate care plan: record all BMs-amount, color, consistency, and time of BM.** *Discontinue immediately if the patient complains of severe discomfort,weakness, or anxiety,or if the nurse observes signs of syncope, that is, weakness, lightheadedness,or change in pulse, skin temperature, or color. **A mild laxativemay be needed until the program is established.Consultwith physician regarding appropriatedrug.
place, and the patient's position remains constant for each measurement. The patient is measured daily and always at the same time. Presence of bowel sounds are determined, and the patient's subjective description of comfort or discomfort is elicited, if possible. This information provides guidelines for establishing a bowel program aimed at preventing complica-
18 Geriatric Nursing January/February1987
tions of acquired megacolon while enhancing patient comfort. Specific nursing interventions will be determined according to the individual needs of the patient (see Sample Care Plan above). A successful method for assisting in maintaining motility and in expelling flatus is the Harris Flush(l 1). This procedtire is a form of colonic irrigation in which a moderate
amount (800ce) of warm tap water is slowly introduced into the rectum. The enema bag is initially held at the level of the bed at the start of the procedure and is gradually raised to 1824 inches above the level of the bed to ensure continuous flow into the rectum. As soon as the fluid is completely emptied, the bag is lowered below the level of the bed. This procedure has a siphoning effect: It not only withdraws flatus, but also ensures an immediate return of fluid. It is very safe, because it eliminates the possibility of too much water being absorbed by the colon and so reduces the risk of fluid overload to the cardiovascular system. (Since many elderly suffer from compromised cardiac output, absorption of additional water could precipitate an episode of congestive heart failure.) After completion of the Harris Flush, most patients will experience relief from flatus and may show a measurable decrease in abdominal girth. But the flush does not guarantee an immediate return of feces. The colon is grossly distended, and the fluid used in the irrigation may remain in the very lowest portions of the sigmoid, colon, and rectum, while the feces may be above this level. Therefore, bowel movement may be delayed for up to 24 hours. The patient may then expel a large amount of liquid stool (over 1,000cc), and with great force. Such fluid is considered "third space" content, and loss of it does not significantly change hemodynamic status(3). However, sudden evacuation could precipitate defecation syncope, thought to be associated with sudden decompression of the rectum(12). Therefore, close observation of the patient is essential during and after this procedure. In addition to the Harris Flush, other methods to help establish a bowel program may be used. Bulk formers may soften stools, laxatives can move intestinal contents, and suppositories can stimulate evacuation. Providing the patient with a regular elimination time in addition to allowing for privacy are important considerations when planning care. Besides the establishment of a bowel program, several other factors
are important to consider in planning nursing interventions. Measures to provide comfort and promote activity tolerance, maintenance of pulmonary hygiene, nutritional counseling, and emotional support should be included in the care plan(l 3). A diet ensuring that the patient is receiving and tolerating appropriate amounts of roughage and fluids must be planned. For example, if the patient has trouble chewing, prune juice or bran added to warm cereal may be substituted for fresh fruits and vegetables. The patient's progress may be evaluated during hospitalization in order to make necessary adjustments before discharge. The patient with acquired megacoIon may be experiencing considerable abdominal distention which may place pressure on the diaphragm, thus compromising the ability to ful-
ly expand the lungs. The patient is at risk to develop complications such as atelectasis or pneumonia (see x ray of lung showing atelectasis). Thus it is essential to encourage coughing and deep breathing and to frequently change the patient's position. Comfort measures include positioning the patient according to his or her own preference. (Positioning the patient at a 45-degree angle while in bed will not serve to alleviate pressure on the diaphragm.) Most patients will want to sit upright and use a footstool, which will help prevent dependent edema. Activities such as bathing and ambulation should be planned with frequent rest periods. However, as the patient's physical status improves, the nurse and patient may plan activities aimed at increasing tolerance to physical activity in preparation for discharge. Many elderly patients are quite
ETIOLOGIES OF ADULT ACQUIRED MEGACOLON CATEGORY
EXAMPLE
OBSTRUCTION Intrinsic
Tumor Stricture
Radiation Extrinsic
Tumor Adhesion Endometriosis Radiation
PSYCHIATRIC
Psychosis Neurosis Dementia
NEUROLOGICAL
Parkinson's disease Multiple sclerosis Cord lesions Drugs Dystrophies
CONNECTIVE TISSUE DISEASE
Progressive systemic sclerosis Lupus Amyloidosis
METABOLIC
Hypokalemia Hypocalcemia Hypothyroidism Diabetes Lead poisoning
MISCELLANEOUS
Idiopathic Pseudo obstruction Laxative abuse Painful back Pelvic conditions Irritable bowel syndrome
preoccupied with bowel functioning. It is important to recognize that this concern may become magnified during hospitalization for acquired megacolon. As a result, suggestions for appreciable changes in everyday routines may be met with considerable resistance, and attempts to change habits of a lifetime are probably fruitless. Nursing efforts are perhaps best directed toward preventing complications. The nurse can establish a relationship with the patient based on trust only in a nonjudgmental and supportive environment; in this way, he or she can work to alleviate the patient's concerns. Acquired megacolon is a condition that can be treated successfully in the elderly population through a collaborative effort on the part of physician, nurse, and patient. Promotion of a bowel maintenance program and a care plan designed to increase activity levels and enhance comfort may be successfully applied in any care setting. References I. Stefll, B. M., ed. lIandbook of Gerontological Nursing. New York, Van Nostrand Reinhold Co., 1984. 2. Spiro, H. M. Clinical Gastroenterology 3rd ed. New York, Maemillian Publishing Co., 1983. 3. Guyton, A. C. Textbook of Medicol Physiology 7th ed. Philadelphia, W.B. Saunders Co., 1986. 4. Sleisenger,M. H., and Fordtran, J. S. Gastrointes-
tinal Disease: Pathophysiology Diagnosis Management. Philadelphia, W.B. Saunders Co. (To be published) 5. Andres, R., and Hazzard, W. R. Principles of Geriatric Medicine. New York, McGraw-Hill Book Co., 1984. 6. Taylor, I., and others. An assessment ofanorectal motility in the management of adult megacolon. Br.J.Surg. 67:754-756, Oct. 1980. 7. Ryan, P. Sigmoid volvulus with and without magacolon. Dis.Colon Rectunt 25:673-679, Oct. 1982. 8. Brocklehurst, J. C. Disorders of the Lower bowel in old age. Geriatrics 35:47-54, May 1980. 9. Gioiella, E., and Bevil, C. Nursing CareoftheAging Client. East Norwalk, CT, Appleton-CenturyCrofts, 1984. 10. Bruuner, Lilian, and Suddarth, Doris. Textbook of Medical-Surgical Nursing. 5th Ed. Philadelphia, J.B. Lippincolt Co., 1984. I I. King. E. M., and others. Illustrated Manual of Nursing Techniques. Philadelphia, J.B." Lippincott Co., 1977. (2nd ed. 1981) 12. Hurst. J. W. The tteart. 6th ed. New York, McGraw-Hill Book Co., 1986. 13. Carpenito, L. J. Nursing Diagnosis: Application to ClinicalPractice. Philadelphia, J.B. Lippincott Co., 1983.
Acknowledgment We would like to thank Lincoln Russin, MD, and Bridget Bedard, BA, for their help with taking the photographs that appear in this article.
Geriatric Nursing January/February 1987 19